UNASSIGNED: Recent studies have shown inconsistent results regarding the association between QRS characteristics and survival outcomes in patients with cardiac arrest and pulseless electrical activity (PEA) rhythms. This meta-analysis aimed to identify the usefulness of QRS width and frequency as prognostic tools for outcomes in patients with cardiac arrest and PEA rhythm.
UNASSIGNED: Extensive searches were conducted using Medline, Embase, and the Cochrane Library to find articles published from database inception to 4 June 2023. Studies that assessed the association between the QRS characteristics of cardiac arrest patients with PEA rhythm and survival outcomes were included. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies.
UNASSIGNED: A total of 9727 patients from seven observational studies were included in this systematic review and meta-analysis. The wide QRS group (QRS ≥ 120 ms) was associated with significantly higher odds of mortality than the narrow QRS group (QRS < 120 ms) (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.11-3.11, I2 = 58%). The pooled OR for mortality was significantly higher in patients with a QRS frequency of < 60/min than in those with a QRS frequency of ≥ 60/min (OR = 1.90, 95% CI = 1.19-3.02, I2 = 65%).
UNASSIGNED: Wide QRS width or low QRS frequency is associated with increased odds of mortality in patients with PEA cardiac arrest. These findings may be beneficial to guide the disposition of cardiac arrest patients with PEA during resuscitation.

UNASSIGNED: Blood-based biomarkers play a central role in the diagnosis and treatment of critically ill patients, yet none are routinely measured during the intra-arrest phase of out-of-hospital cardiac arrest (OHCA). Our objective was to describe methodological aspects, sources of evidence, and gaps in research surrounding intra-arrest blood-based biomarkers for OHCA.
UNASSIGNED: We used scoping review methodology to summarize existing literature. The protocol was designed a priori following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. Inclusion criteria were peer-reviewed scientific studies on OHCA patients with at least one blood draw intra-arrest. We excluded in-hospital cardiac arrest and animal studies. There were no language, date, or study design exclusions. We conducted an electronic literature search using PubMed and Embase and hand-searched secondary literature. Data charting/synthesis were performed in duplicate using standardized data extraction templates.
UNASSIGNED: The search strategy identified 11,834 records, with 118 studies evaluating 105 blood-based biomarkers included. Only eight studies (7%) had complete reporting. The median number of studies per biomarker was 2 (interquartile range 1-4). Most studies were conducted in Asia (63 studies, 53%).  Only 22 studies (19%) had blood samples collected in the prehospital setting, and only six studies (5%) had samples collected by paramedics. Pediatric patients were included in only three studies (3%). Out of eight predefined biomarker categories of use, only two were routinely assessed: prognostic (97/105, 92%) and diagnostic (61/105, 58%).
UNASSIGNED: Despite a large body of literature on intra-arrest blood-based biomarkers for OHCA, gaps in methodology and knowledge are widespread.

A diaphragmatic hernia is a protrusion of the abdominal contents into the negative pressure thoracic cavity through a congenital or acquired diaphragmatic defect. Generally, acquired diaphragmatic hernia is a rare, life-threatening condition that usually follows blunt/penetrating trauma or an iatrogenic cause, resulting in the diaphragmatic rupture, accompanied by the herniation of abdominal visceral organs. We report a 47-year-old male construction worker who sustained a fall from a height of about 30 feet height. He presented with hypoxia initially and, after a primary survey, was found to have a traumatic rupture of the diaphragm with herniation of the stomach and abdominal contents, causing signs of obstructive shock. After adequate resuscitation in the Emergency Department, he was rushed to operating room. There, he suffered two very short pulseless electrical activity cardiac arrests. Therefore, an emergency anterolateral thoracotomy was done, and it was extended into laparotomy to reduce the abdominal contents through the diaphragmatic tear of 12 cm, which restored the spontaneous circulation. He recovered eventually, despite chest infections and pulmonary atelectasis, and was discharged on the 28th day and remained in good condition during the outpatient visit. Tension gastrothorax or viscerothorax is rare, but an under-recognized cause of cardiac arrest in the trauma setting necessitates a vigilant evaluation and early suspicion to prevent a catastrophic outcome. This case report emphasizes the inclusion of tension viscero or abdominal thorax as one of the recognizable causes of a pulseless electrical activity cardiac arrest.

UNASSIGNED: Out-of-hospital cardiac arrest patients with pulseless electrical activity are treated by paramedics using basic and advanced life support resuscitation. When resuscitation fails to achieve return of spontaneous circulation, there are limited evidence and national guidelines on when to continue or stop resuscitation. This has led to ambulance services in the United Kingdom developing local guidelines to support paramedics in the resuscitative management of pulseless electrical activity. The content of each guideline is unknown, as is any association between guideline implementation and patient survival. We aim to identify and synthesise local ambulance service guidelines to help improve the consistency of paramedic-led decision-making for the resuscitation of pulseless electrical activity in out-of-hospital cardiac arrest.
UNASSIGNED: A systematic review of text and opinion will be conducted on ambulance service guidelines for resuscitating adult cardiac arrest patients with pulseless electrical activity. Data will be gathered direct from the ambulance service website. The review will be guided by the methods of the Joanna Briggs Institute (JBI). The search strategy will be conducted in three stages: 1) a website search of the 14 ambulance services; 2) a search of the evidence listed in support of the guideline; and 3) an examination of the reference list of documents found in the first and second stages and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Each document will be assessed against the inclusion criteria, and quality of evidence will be assessed using the JBI Critical Appraisal Checklist for Text and Opinion. Data will be extracted using the JBI methods of textual data extraction and a three-stage data synthesis process: 1) extraction of opinion statements; 2) categorisation of statements according to similarity of meaning; and 3) meta-synthesis of statements to create a new collection of findings. Confidence of findings will be assessed using the graded ConQual approach.

Current criteria used to make the clinical diagnosis of fat embolism syndrome were never intended to be applied to an anesthetized, mechanically ventilated patient in the operating room and, as such, may not be applicable during intraoperative care. Because of this, confusion still exists among anesthesia providers in recognizing this potentially fatal clinical condition. Our goal was to develop and then present a more exacting and rigorous grading scale, tailored specifically for the anesthetized patient, with the hope that it will aid clinicians in recognizing and successfully managing the manifestations of the syndrome. A thorough review of the proposed mechanisms of fat embolism syndrome is provided, as well as a brief case report detailing a pediatric patient who experienced cardiovascular collapse during intramedullary nailing of a femur fracture. Also included is a proposal for new clinical guidelines for the intraoperative diagnosis of fat embolism.

Cardiac amyloidosis is associated with a high rate of sudden cardiac death (SCD). Whether implantable cardioverter-defibrillator (ICD) use in such patients prevents SCD is uncertain. This study assesses outcomes of ICD use in patients with cardiac amyloidosis.
A systematic review and meta-analysis of data were performed after searching multiple databases and scientific sites pertaining to ICD use and cardiac amyloidosis. Of 8260 citations identified, six studies comprising 194 patients met inclusion criteria.
Mean values and frequencies of patient characteristics were as follows: mean NT-proBNP: 6867.9 pg/mL, mean left ventricular ejection fraction: 48.1%, heart failure: 67%, nonsustained ventricular tachycardia: 51%, syncope: 21%, and secondary prevention: 33%. During the mean follow-up period of 18.21 months, 18% of patients received appropriate ICD treatment and 5% received inappropriate ICD treatment. The mortality rate was 31%. Two studies assessed the difference between patients with appropriate ICD treatment and patients with absence of appropriate ICD treatment. There was no difference between the two groups when stratified on multiple selected third variables except for two subgroups. Male gender was associated with a higher rate of appropriate ICD treatment, whereas New York Heart Association class III or IV heart failure patients was associated with a lower rate of appropriate ICD treatment.
The frequency of appropriate ICD treatment in cardiac amyloidosis is low and is not predicted by nonsustained ventricular tachycardia. Male gender is associated with appropriate ICD treatment. New York Heart Association class III or IV heart failure is associated with lower rate of appropriate ICD treatment.

BACKGROUND: Cardiac arrest management primarily focuses on optimal chest compressions and early defibrillation for shockable cardiac rhythms. Non-shockable rhythms such as pulseless electrical activity (PEA) and asystole present challenges in management. Point-of-care ultrasound (POCUS) in cardiac arrest is promising.
OBJECTIVE: This review provides a focused assessment of POCUS in cardiac arrest, with an overview of transthoracic (TTE) and transesophageal echocardiogram (TEE), uses in arrest, and literature support.
CONCLUSIONS: Cardiac arrest can be distinguished between shockable and non-shockable rhythms, with management varying based on the rhythm. POCUS provides a diagnostic and prognostic tool in the emergency department (ED), which may improve accuracy in clinical decision-making. Several protocols incorporate POCUS based on different cardiac views. TTE includes parasternal long axis, parasternal short axis, apical 4-chamber, and subxiphoid views, which may be used in cardiac arrest for diagnosis of underlying cause and potential prognostication. TEE is conducted by inserting the probe into the esophagus of intubated patients, with several studies evaluating its use in cardiac arrest. It is associated with few adverse effects, while allowing continued compressions (and evaluation of those compressions) and not interrupting resuscitation efforts.
CONCLUSIONS: POCUS is a valuable diagnostic and prognostic tool in cardiac arrest, with recent literature supporting its diagnostic ability. TTE can guide resuscitation efforts dependent on the rhythm, though TTE should not interrupt other resuscitation measures. TEE can be useful during arrest, but further studies based in the ED are needed.

BACKGROUND: Cardiac arrest is a common presentation to the emergency care system. The decision to terminate CPR is often challenging to heath care providers. An accurate, early predictor of the outcome of resuscitation is needed. The purpose of this systematic review is to evaluate the prognostic value of ETCO2 during cardiac arrest and to explore whether ETCO2 values could be utilised as a tool to predict the outcome of resuscitation.
METHODS: Literature search was performed using Medline and EMBASE databases to identify studies that evaluated the relationship between ETCO2 during cardiac arrest and outcome. Studies were thoroughly evaluated and appraised. Summary of evidence and conclusions were drawn from this systematic literature review.
RESULTS: 23 observational studies were included. The majority of studies showed that ETCO2 values during CPR were significantly higher in patients who later developed ROSC compared to patients who did not. Several studies suggested that initial ETCO2 value of more than 1.33 kPa is 100% sensitive for predicting survival making ETCO2 value below 1.33 kPa a strong predictor of mortality. These studies however had several limitations and the 100% sensitivity for predicting survival was not consistent among all studies.
CONCLUSIONS: ETCO2 values during CPR do correlate with the likelihood of ROSC and survival and therefore have prognostic value. Although certain ETCO2 cut-off values appears to be a strong predictor of mortality, the utility of ETCO2 cut-off values during CPR to accurately predict the outcome of resuscitation is not fully established. Therefore, ETCO2 values cannot be used as a mortality predictor in isolation.